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Dental Expense Benefits - Classic

A. DEFINITIONS

"Covered Dental Expense" means:

1. For In-Network Benefits

The charges based on the Preferred Dentist Program Table of Maximum Allowed Charges for the types of dental services shown in section C. These services must be:

performed or prescribed by a Dentist who is a Participating Provider, or for Emergency Services, must be performed or prescribed by a Dentist; and
necessary in terms of generally accepted dental standards.

No more than the Maximum Allowed Charge for the types of dental services shown in section C will be covered by the Dental Expense Benefits. The Maximum Allowed Charge is the lower of:

the amount charged by the Participating Provider for the service or supply; and
the maximum amount that the Participating Provider agreed with us to charge for that service or supply. This maximum amount is specified or based on the amounts specified in the Preferred Dentist Program Table of Maximum Allowed Charges.

2. For Out-of-Network Benefits

The charges for the types of dental services shown in section C. These services must be:

performed or prescribed by a Dentist who is not a Participating Provider; and
necessary in terms of generally accepted dental standards.

No more than the Reasonable and Customary Charge for the types of dental services shown in section C will be covered by the Dental Expense Benefits. The Reasonable and Customary Charge is the lowest of:

the usual charge by the Dentist or other provider of the services or supplies for the same or similar services or supplies; or
the usual charge of most other Dentists or other providers in the same geographic area for the same or similar services or supplies; or
the actual charge for the services or supplies.

There may be more than one way to treat a dental problem. If, in our view, an adequate method or material which costs less could have been used, the Dental Expense Benefits will be based on the method or material which costs less. The rest of the cost will not be a Covered Dental Expense. See section E for examples that show how this works.

"Deductible Amount" means the amount shown in the SCHEDULE OF BENEFITS. The Deductible Amount is an annual amount.

The Deductibles during any one Dental Expense Period will not apply to Covered Dental Expenses for your Family after you incur Covered Dental Expenses for Covered Persons in your Family and those expenses equal the Family Deductible Amount.

"Dental Expense Period" means a period which starts on any January 1 and ends on the next December 31.

"Dentist" means a person licensed by law or regulation to practice dentistry. A type of dental service which is performed or prescribed by a Doctor will be considered for Dental Expense Benefits as if it were performed or prescribed by a Dentist.

"Emergency Services" means the type of dental services listed in Section C when those services are provided or performed by a Dentist who is not a Participating Provider after the sudden onset of a medical condition manifesting itself by acute symptoms, including severe pain, which are severe enough that the lack of immediate dental attention could be reasonably expected to result in:

1. placing the Covered Person’s health in serious jeopardy; or

2. serious impairment of bodily functions; or

3. serious dysfunction of any bodily function or part.

If a Covered Person cannot reasonably reach a Participating Provider, payment for services will be made in the same manner as if the Covered Person had been treated by a Participating Provider. For most purposes, Benefits for Emergency Services are considered as In-Network Benefits and are subject to the In-Network Deductible, the In-Network Covered Percentage and all In-Network Maximum Amounts. As with all other services provided by a Non-Participating Provider, the amount of covered charges will be based on the Reasonable and Customary Charge. However, unlike with a Participating Provider, there is no agreement between a Non-Participating Provider and us for the Provider to limit what the Dentist charges you for the Emergency Services.

"In-Network Covered Percentage" and “Out-of-Network Covered Percentage” mean the percentages shown in the SCHEDULE OF BENEFITS.

"In-Network Benefits" means the Dental Expense Benefits provided under This Plan for covered dental services that are provided by a Dentist who is a Participating Provider or covered Emergency Services that are provided by a Dentist who is not a Participating Provider.

"Out-of-Network Benefits" means the Dental Expense Benefits provided under This Plan for covered dental services that are provided by a Dentist who is not a Participating Provider, unless those services are covered Emergency Services and considered for In-Network Benefits.

"Preferred Dentist Program Table of Maximum Allowed Charges" means the table of charges referred to in our fee agreement with a Participating Provider in which such Participating Provider has agreed to accept a schedule of maximum fees as payment in full for services rendered.

"Preferred Dentist Program" means our program to offer a Covered Person the opportunity to receive dental care from Dentists who are designated by us as Participating Providers. When dental care is given by Participating Providers, the Covered Person will generally incur less out-of-pocket cost for the services rendered.

"Participating Provider" means a Dentist who has been selected by us for inclusion in the Preferred Dentist Program. These Participating Providers agree to accept our Preferred Dentist Program Table of Maximum Allowed Charges as payment in full for services rendered.

"Non-Participating Provider" means a Dentist who is not a Participating Provider.

"Preferred Dentist Program Directory" means the list which consists of selected Dentists who:

are located in the Covered Person's area; and
have been selected by us to be Participating Providers and part of the Preferred Dentist Program. These Participating Providers agree to accept our Preferred Dentist Program Table of Maximum Allowed Charges as payment in full for services rendered.

The list will be periodically updated.

B. COVERAGE

1. When Benefits May Be Payable

We will pay Dental Expense Benefits if you incur In-Network Covered Dental Expenses:

a. for a Covered Person during a Dental Expense Period; and

b. while you are covered for the Dental Expense Benefits for that Covered Person; and

c. the In-Network Covered Dental Expenses are more than the In-Network Deductible Amount.

We recommend that you identify yourself to the Participating Provider as a member in the Preferred Dentist Program at the time that Covered Services are provided. We also recommend that you confirm at the time that the dentist is currently a Participating Provider. If you do not identify yourself as a member in the Preferred Dentist Program, this will not change the benefit determination or the amount which the Participating Provider may finally charge you. However, if the Participating Provider is not aware that you are a member in the Preferred Dentist Program, the Participating Provider might at first charge you the amount that the Participating Provider charges patients who are not members of the Preferred Dentist Program. That is why we recommend that you identify yourself as a member of the Preferred Dentist Program at the time that Covered Services are provided. We will also pay Dental Expense Benefits if you incur Out-of-Network Covered Dental Expenses:

a. for a Covered Person during a Dental Expense Period; and

b. while you are covered for the Dental Expense Benefits for that Covered Person; and

c. the sum of the In-Network Covered Dental Expenses and Out-of-Network Covered Dental Expenses are more than the Out-of-Network Deductible Amount.

An expense is "incurred" on the date the type of dental service for which the charge is made is completed.

2. How Benefits Are Determined

In-Network Benefits will be equal to the Covered Percentage of those In-Network Covered Dental Expenses which are more than the In-Network Deductible Amount. Out-of-Network Benefits will be equal to the Covered Percentage of the Out-of-Network Covered Dental Expenses which are more than the Out-of-Network Deductible Amount. However:

a. No more benefits will be payable for In-Network Covered Dental Expenses after the sum of In-Network Covered Dental Expenses and Out-of-Network Covered Dental Expenses equal the In-Network Maximum Benefit for One Dental Expense Period shown in the SCHEDULE OF BENEFITS; and

b. No more benefits will be payable for Out-of-Network Covered Dental Expenses after the sum of In-Network Covered Dental Expenses and Out-of-Network Covered Dental Expenses equal the Out-of-Network Maximum Benefit for One Dental Expense Period shown in the SCHEDULE OF BENEFITS; and

c. The sum of all benefits for all Covered Dental Expenses incurred for a Covered Person for orthodontic treatment during all Dental Expense Periods will not be more than the applicable Aggregate Maximum Benefit For All Dental Expense Periods as shown in the SCHEDULE OF BENEFITS.

In order to determine what are the amounts of Covered Dental Expenses, we may ask for X-rays and other diagnostic and evaluative materials. If they are not given to us, we will determine Covered Dental Expenses on the basis of the information which is available to us. This may reduce the amount of benefits which otherwise would have been payable.

3. How the Preferred Dentist Program Works

Free Choice Of A Dentist:

A Covered Person is always free to choose the services of a Dentist who is either:

a. a Participating Provider; or

b. a Non-Participating Provider.

Benefits under This Plan will be determined and paid in either case, except that the Covered Person will generally incur less out-of-pocket cost if a Participating Provider is chosen.

C. DENTAL SERVICES WHICH MAY BE COVERED DENTAL EXPENSES

1. Type A Expenses

a. Oral exams but not more than once every 6 months.

b. X-rays:

i. full mouth X-rays but not more than once every 60 months; and

ii. bitewing X-rays but not more than once every 6 months.

c. Preventive treatment:

i. scaling and polishing of teeth (oral prophylaxis) but not more than once every 6 months; and

ii. topical fluoride treatment for Dependent children under 19 years of age, but not more than once every 6 months.

e. Space maintainers for a Dependent child under 19 years of age.

f. Sealants which are applied to non-restored, nondecayed, first and second permanent molars only, for a Dependent child up to 15 years of age every 48 months.

g. Emergency palliative treatment.

2. Type B Expenses

a. Amalgam or resin fillings.

b. Extractions.

c. Consultations twice a year.

d. Root canal treatment, but no more than one time for the same tooth every 24 months.

e. Treatment of periodontal disease and other diseases of the gums and tissues of the mouth, unless specifically mentioned in this section.

f. Periodontal scaling and root planning but not more than once per quadrant every 24 months.

g. Periodontal surgery, including gingivectomy or gingivoplasty, gingival curettage, osseous surgery, bone replacement graft, and guided tissue regeneration.

h. Periodontal maintenance where periodontal treatment (such as osseous surgery, gingivectomy, gingivoplasty, or gingival curettage) has been previously performed, the number of covered periodontal maintenance treatments will not exceed four treatments in a Dental Expense Period.

i. Oral surgery.

j. Administration of general anesthesia, when dentally necessary in terms of generally accepted dental standards in connection with oral surgery, extractions, or other covered dental services.

k. Injections of antibiotic drugs.

l. Relinings and rebasings of existing removable dentures but not more than once in 36 months.

m. Repair or re-cementing of:

i. crowns; or

ii. inlays or onlays; or

iii. dentures; or

iv. bridgework.

n. Adding teeth to an existing partial removable denture or to bridgework when needed to replace one or more natural teeth removed after the existing denture or bridgework was installed.

3. Type C Expenses

a. Those services needed to replace one or more natural teeth which are lost while Dental Expense Benefits for the Covered Person are in effect for:

i. Installation of fixed bridgework done for the first time.

ii. Installation for the first time of:

1. a partial removable denture; or

2. a full removable denture.

b. Replacing an existing removable denture or fixed bridgework if it is needed because the existing denture or bridgework is no longer serviceable and was installed at least 60 months prior to its replacement.

c. Replacing an existing immediate temporary full denture by a new permanent full denture when:

i. the existing denture can not be made permanent; and

ii. the permanent denture is installed within 12 months after the existing denture was installed.

d. Inlays, onlays and crown restorations, but not more than one such restoration to the same tooth surface within 60 months of the prior restoration.

EXCLUSIONS - DENTAL SERVICES WHICH ARE NOT COVERED DENTAL EXPENSES

1. Services or supplies received by a Covered Person before the Dental Expense Benefits start for that person.

2. Services not performed by a Dentist except for those services of a licensed dental hygienist which are supervised and billed by a Dentist and which are for:

a. scaling and polishing of teeth; or

b. fluoride treatments.

3. Services or supplies which are not necessary in terms of generally accepted dental standards, as determined by us.

4. Cosmetic surgery or supplies. However, any such surgery or supply will be covered if:

a. it otherwise is a Covered Dental Expense; and

b. it is required for reconstructive surgery which is incidental to or follows surgery which results from a trauma, an infection or other disease of the involved part; or

c. it is required for reconstructive surgery because of a congenital disease or anomaly of a Dependent child which has resulted in a functional defect.

5. Replacement of a lost, missing or stolen crown, bridge or denture.

6. Services or supplies which are covered by any workers' compensation laws or occupational disease laws.

7. Services or supplies which are covered by any employers' liability laws.

8. Services or supplies which any employer is required by law to furnish in whole or in part.

9. Services or supplies received through a medical department or similar facility which is maintained by the Covered Person's employer.

10. Services or supplies received by a Covered Person for which no charge would have been made in the absence of Dental Expense Benefits for that Covered Person.

11. Services or supplies for which a Covered Person is not required to pay.

12. Services or supplies which are deemed experimental in terms of generally accepted dental standards.

13. Services or supplies received as a result of dental disease, defect or injury due to an act of war, or a warlike act in time of peace, which occurs while the Dental Expense Benefits for the Covered Person are in effect.

14. Adjustment of a denture or a bridgework which is made within 6 months after installation by the same Dentist who installed it.

15. Any duplicate appliance or prosthetic device.

16. Use of material or home health aids to prevent decay, such as toothpaste or fluoride gels, other than the topical application of fluoride.

17. Instruction for oral care such as hygiene or diet.

18. Periodontal splinting.

19. Temporary or provisional restorations.

20. Temporary or provisional appliances.

21. Services or supplies to the extent that benefits are otherwise provided under This Plan or under any other plan which the Policyholder (or an affiliate) contributes to or sponsors.

22. Myofunctional therapy or correction of harmful habits.

23. Implantology.

24. Initial installation of a denture or bridgework to replace one or more natural teeth lost before the Dental Expense Benefits started for the Covered Person or as a replacement for congenitally missing natural teeth.

25. Charges for broken appointments.

26. Charges by the Dentist for completing dental forms.

27. Sterilization supplies.

28. Services or supplies furnished by a family member.

29. Treatment of temporomandibular joint disorders.

30. Orthodontia.

31. Appliances or treatment for bruxism (grinding teeth), including but not limited to occlusal quarels and night guards.

E. EXAMPLES OF ALTERNATE BENEFITS

Dental Expense Benefits will be based on the materials and method of treatment which cost the least and which, in our view, meet generally accepted dental standards.

1. Inlays, Onlays, Crowns and Gold Foil

If a tooth can be repaired to our satisfaction according to generally accepted dental standards by a less costly method than an inlay, onlay, crown or gold foil, Dental Expense Benefits will be based on the adequate method of repair which costs the least.

2. Bridgework and Dentures

Dental Expense Benefits will be based on the adequate method of treating the dental arch which costs the least. In some cases removable dentures may serve as well as fixed bridgework. If dentures are replaced by fixed bridgework, the Dental Expense Benefits will be based on the cost of a replacement denture unless adequate results can only be achieved with fixed bridgework. These are not the only examples of alternate benefits. To find out how much your Dental Expense Benefits will be, see section F.

F. PRE-DETERMINATION OF BENEFITS

If a dental bill is expected to be $300 or more, before the Dentist starts the treatment, a Covered Person can find out what Dental Expense Benefits will be paid under This Plan. To do this, the Covered Person should send a claim form to us in which the Dentist tells us:

1. the work to be done; and

2. what the cost will be.

We will then tell the Covered Person what Dental Expense Benefits This Plan may pay. If the Covered Person does not use this method to find out what Dental Expense Benefits This Plan may pay, our decision will be final and binding with regard to what are Covered Dental Expenses and what Dental Expense Benefits This Plan may pay.

This method should not be used for:

1. emergency treatment; or

2. routine oral exams; or

3. X-rays, scaling and polishing, and fluoride treatments; or

4. dental services which cost less than $300.

G. IMPACT OF GOVERNMENT PLANS ON DENTAL EXPENSE BENEFITS

To the extent that services or supplies, or benefits for them, are available to a Covered Person under a Government Plan, as defined below, they will not be considered for Dental Expense Benefits under This Plan. This provision will apply whether or not the Covered Person is enrolled for all Government Plans for which that Covered Person is eligible. This provision will not apply to a Government Plan if that Government Plan requires that Dental Expense Benefits under This Plan be paid first. A "Government Plan" is any plan, program or coverage, other than Medicare:

1. which is established under the laws or the regulations of any government; or

2. in which any government participates other than as an employer.

H. DENTAL EXPENSE COVERAGE AFTER BENEFITS END

No benefits will be payable for Covered Dental Expenses incurred by a Covered Person after the Dental Expense Benefits for that person end. This will apply even if we have pre-determined benefits for dental services. However, benefits for Covered Dental Expenses incurred for a Covered Person for the following services will be paid after Dental Expense Benefits end:

1. For a prosthetic device if:

a. the Dentist prepared the abutment teeth and made final impressions while Dental Expense Benefits for the Covered Person were in effect; and

b. the device is installed within 31 days after the date the Dental Expense Benefits end; or

2. For a crown if:

a. the Dentist prepared the tooth for the crown while the Dental Expense Benefits for the Covered Person were in effect; and

b. the crown is installed within 31 days after the date the Dental Expense Benefits end; or

3. For root canal therapy if:

a. the Dentist opened into the pulp chamber while the Dental Expense Benefits for the Covered Person were in effect; and

b. the treatment is finished within 31 days after the date the Dental Expense Benefits end.

I. PAYMENT OF BENEFITS

Dental Expense Benefits will be paid to you. If you have any questions about your claim or the Preferred Dentist Program, please call us at 1-800-942-0854. We will pay benefits when we receive satisfactory written proof of your claim. If instead of providing us with proof of a claim, you provide us with notice of a claim, we will furnish you with claim forms within 15 days of our receipt of that notice. For purposes of this section, “notice of a claim” means any notification:

1. in writing or otherwise; and

2. made to us by you; and

3. asserting right to payment for Dental Expense Benefits under This Plan; and

4. which reasonably apprises us of the existence of a claim. Within forty-five days of our receipt of the notice, if payment is not made, we shall notify you in writing specifying reasons for the non-payment or whatever documentation is necessary for payment of said claim.

If we do not comply with the provisions of this section, we shall pay, in addition to any Dental Expense Benefits payable, interest on such benefits which shall accrue beginning forty-five days after our receipt of notice of claim at the rate of one and one-half percent per month, not to exceed eighteen percent per year. The provisions of this paragraph shall not apply to a claim which we are investigating because of suspected fraud. Proof must be given to us not later than 90 days after the end of the Dental Expense Period in which the Covered Dental Expenses were incurred. If proof is not given on time, the delay will not cause a claim to be denied or reduced as long as the proof is given as soon as possible.